Integration of Perforator Vessels in CAD/CAM Free Fibula Graft Planning: A Clinical Feasibility Study

  • Elisabeth GoetzeEmail author
  • Peer W. Kämmerer
  • Bilal Al-Nawas
  • Maximilian Moergel
Original Article



Commercial CAD/CAM planning of free osteocutaneous microvascular fibula flap does not support integration of soft tissue structures including perforator vessel anatomy. Therefore, in a clinical trial, a method for such a combined hard- and soft tissue 3D-fibula planning was assessed.

Materials and Methods

In a clinical study on 24 patients needing reconstruction with osteocutaneous fibula graft, skin perforators of the respective leg were detected via Doppler sonography and documented on a measurement device. Each of the perforators’ localization was transferred to a CAD/CAM planning software and included in each planning step as well as in the surgical cutting guide. A comparison between sonography and clinical localization, damage to perforator vessels during surgery as well as a subjective evaluation of feasibility and usefulness of the procedure was carried out.


In total, 19 skin paddles were placed orally, 2 extraorally and 3 at both sites at once. Survival rate was 92% (22/24). In addition, 3 skin paddles were lost complete and 2 partially. Anatomical sites of perforator vessels were never < 1 cm from planned positions and not damaged at all (n = 75). Planning was judged useful for skin paddle design and positioning of osteotomies. In accordance, surgical guides were always implemented successfully without the need of changing planned procedures during surgery.


Integration of skin perforators into 3D planning of microvascular fibular graft is feasible and may even decrease involuntary dissection of perforator vessels. Even so, clinical studies for comparison are needed.


Head and neck cancer Reconstruction Osteocutaneous microvascular flap Perforator anatomy CAD/CAM Computer aided 



This research did not receive any specific grant from funding agencies in the public, commercial or not-for-profit sectors. People shown gave written consent in publication of their photographs. We would like to thank Ms. Tina Rodemer for volunteering for the pictures.

Compliance with Ethical Standards

Conflict of interest

The authors state that there is no conflict of interest.


  1. 1.
    Taylor GI, Miller GD, Ham FJ (1975) The free vascularized bone graft. A clinical extension of microvascular techniques. Plast Reconstr Surg 55(5):533–544CrossRefGoogle Scholar
  2. 2.
    Hidalgo DA (1989) Fibula free flap: a new method of mandible reconstruction. Plast Reconstr Surg 84(1):71–79CrossRefGoogle Scholar
  3. 3.
    Hölzle F, Franz EP, von Diepenbroick VH, Wolff KD (2003) Evaluation der Unterschenkelarterien vor mikrochirurgischem Fibulatransfer. Mund Kiefer GesichtsChir 7(4):246–253. CrossRefGoogle Scholar
  4. 4.
    Kansy K, Mueller AA, Mücke T, Kopp J-B, Koersgen F, Wolff KD et al (2014) Microsurgical reconstruction of the head and neck—current concepts of maxillofacial surgery in Europe. J Cranio Maxillofac Surg 42(8):1610–1613. CrossRefGoogle Scholar
  5. 5.
    Winters HA, de Jongh GJ (1999) Reliability of the proximal skin paddle of the osteocutaneous free fibula flap: a prospective clinical study. Plast Reconstr Surg 103(3):846–849CrossRefGoogle Scholar
  6. 6.
    Iorio ML, Cheerharan M, Olding M (2012) A systematic review and pooled analysis of peroneal artery perforators for fibula osteocutaneous and perforator flaps. Plast Reconstr Surg 130(3):600–607. CrossRefGoogle Scholar
  7. 7.
    Wolff KD, Bauer F, Wylie J, Stimmer H, Hölzle F, Kesting M (2012) Peroneal perforator flap for intraoral reconstruction. Br J Oral Maxillofac Surg 50(1):25–29. CrossRefGoogle Scholar
  8. 8.
    Futran ND, Stack JBC, Zaccardi MJ (1998) Preoperative color flow Doppler imaging for fibula free tissue transfers. Ann Vasc Surg 12(5):445–450. CrossRefGoogle Scholar
  9. 9.
    Rodby KA, Turin S, Jacobs RJ, Cruz JF, Hassid VJ, Kolokythas A et al (2014) Advances in oncologic head and neck reconstruction: systematic review and future considerations of virtual surgical planning and computer aided design/computer aided modeling. J Plast Reconstr Aesthet Surg 67(9):1171–1185. CrossRefGoogle Scholar
  10. 10.
    Rohner D, Guijarro-Martínez R, Bucher P, Hammer B (2013) Importance of patient-specific intraoperative guides in complex maxillofacial reconstruction. J Cranio Maxillofac Surg 41(5):382–390. CrossRefGoogle Scholar
  11. 11.
    Alassaf MH, Li W, Joshi AS, Hahn JK (2014) Computer-based planning system for mandibular reconstruction. Stud Health Technol Inform 196:6–10Google Scholar
  12. 12.
    General Assembly of the World Medical A (2014) World Medical Association Declaration of Helsinki: ethical principles for medical research involving human subjects. J Am Coll Dent 81(3):14–18Google Scholar
  13. 13.
    Holzle F, Kesting MR, Holzle G, Watola A, Loeffelbein DJ, Ervens J et al (2007) Clinical outcome and patient satisfaction after mandibular reconstruction with free fibula flaps. Int J Oral Maxillofac Surg 36(9):802–806. CrossRefGoogle Scholar
  14. 14.
    Ribuffo D, Atzeni M, Saba L, Guerra M, Mallarini G, Proto E et al (2010) Clinical study of peroneal artery perforators with computed tomographic angiography: implications for fibular flap harvest. Surg Radiol Anat 32(4):329–334. CrossRefGoogle Scholar
  15. 15.
    Saba L, Atzeni M, Rozen WM, Alonso-Burgos A, Bura R, Piga M et al (2013) Non-invasive vascular imaging in perforator flap surgery. Acta Radiol 54(1):89–98. CrossRefGoogle Scholar

Copyright information

© The Association of Oral and Maxillofacial Surgeons of India 2019

Authors and Affiliations

  • Elisabeth Goetze
    • 1
    Email author
  • Peer W. Kämmerer
    • 1
  • Bilal Al-Nawas
    • 1
  • Maximilian Moergel
    • 1
  1. 1.Department of Oral, Maxillofacial and Plastic SurgeryUniversity Medical Centre MainzMainzGermany

Personalised recommendations